By H. Pavel. Rhode Island School of Design.

Te screenshot on this page is reproduced with permission from update software 50 To search the library cheap 100mg zithromax free shipping antibiotic used for strep throat, enter your search phrase in the space provided purchase zithromax 250mg without prescription antimicrobial iphone 4 case. Te results will show the total ‘hits’ from the site and the hits from each database. Cochrane systematic reviews are very detailed but each has a structured abstract with the main findings. You can also go to the ‘Tables and Graphs’ section towards the end of the report and click on the studies to see the results of the analysis. For example, the search terms ‘ ’ shows the following systematic review: ‘Local corticosteroid treatment for carpal tunnel syndrome’ Te ‘Tables and Graphs’ area of the review shows one study where corticosteroid treatment was compared to placebo treatment as the comparator with the numbers of patients showing improvement at 1 month as the outcome. Te results showed a statistically significant benefit at one month for the treated group of patients as follows: Number improved % improved at 1 month Hydrocortisone 23/30 77 Placebo 6/30 20 Percentage improved 57 (57 better from 100 treated) because of treatment NNT 100/57 = 1. However, this sort of search does not provide any filtering for quality of the research and you will probably retrieve a large number of articles of variable usefulness. To improve the quality of the studies you retrieve, click on ‘Clinical Queries’ on the sidebar. Source: Te National Center for Biotechnology Information, Te National Library of Medicine, Te National Institute of Health, Department of Health and Human Services 52 Next, enter the type of question you are trying to answer (ie intervention [therapy], diagnosis, aetiology, prognosis). If you click the ‘Sensitivity’ button you will get more articles but some may be less relevant. Now you can enter the term you are looking for to get the full MeSH subject heading list for that topic. Te tutorial is quite detailed and takes about  hours to go right through but it is very helpful. Source: Te National Library of Medicine, Te National Institute of Health, Department of Health and Human Services 54 Your search terms Based on your ‘P I C O’ and question, write down some search terms and synonyms that you can use for your search: Question 1: Question part Question term Synonyms Population/patientPopulation/patient O P Intervention/indicatorIntervention/indicator O II Comparator/control O CC OO Outcome O Results of search Remember to consider truncating words and using the * wildcard symbol, for example: child* rather than children. Question 2: Question part Question term Synonyms Population/patientPopulation/patient O P Intervention/indicatorIntervention/indicator O II Comparator/control O CC OO Outcome O Results of search 55 Results Question 1: Cochrane Library search terms used: Hits Key references: Results (including absolute risk, NNT, etc if possible): PubMed search terms used: Hits Key references: Results (including absolute risk, NNT, etc if possible): 56 Question 2: Cochrane Library search terms used: Hits Key references: Results (including absolute risk, NNT, etc if possible): PubMed search terms used: Hits Key references: Results (including absolute risk, NNT, etc if possible): 57 Reporting back Report back on what you found out during your literature searching session. Literature search findings: 58 Notes 59 Notes 60 EBM step 3: Rapid critical appraisal of Steps in EBM: controlled trials 1. In the previous sessions you have found out how to formulate clinical questions 2. If you have been lucky evidence of outcomes enough to find a Cochrane systematic review about your question, then you available. You might still want to check that, based on the data available, the included studies 3. Critically appraise the are valid and the conclusions drawn are correct for your patient. Evaluate the effectiveness on long-haul flights and whether it is possible to prevent it by wearing elastic and efficiency of the stockings. Prevention of deep vein thrombosis (DVT) on long haul flights P Population/patientPopulation/patient = passengers on long-haul flights II Intervention/indicatorIntervention/indicator = wearing elastic compression stockings CC Comparator/control = no elastic stockings O Outcome = symptomless deep vein thrombosis (DVT) Clinical question: In passengers on long-haul flights, does wearing elastic compression stockings, compared to not wearing elastic stockings, prevent DVT? Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Authors’ conclusion: ‘Wearing of elastic compression stockings during long-haul air travel is associated with a reduction in symptomless DVT. Te process that has been developed by biostatisticians and clinical epidemiologists for assessing trials is called ‘critical appraisal’. To critically appraise the article by Scurr et al, we need to consider some important factors that may cause a difference to be observed, either positive or negative, between a treated and control group in a clinical trial. Tese factors can be summarised as follows: • whether the groups were representative and comparable • whether the outcome measurements were accurate • whether there was a placebo effect • whether the results were real or could have been due to chance. Te first three points tell us about the internal validity of the methods used to conduct the trial. Te last point is related to the size and variation in the effect seen in different subjects. Te best way to ensure that the study groups are representative is to initially select subjects • was the outcome measurement accurate? For comparative studies, once subjects have been recruited for a trial, they must be allocated to either the control or treatment group.

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Confronting serious illness in patients can arouse therapists’ own fears of mortality and feelings of impotence in the face of overwhelming pain generic 500 mg zithromax mastercard antibiotic resistance yahoo, loss 250mg zithromax otc antibacterial essential oils, and disability. Illness in one fam- ily member can have not only emotional but physical repercussions for other family members, especially spouses. Recent studies have supported the con- tention that chronic stress—especially the stress of caring for a chronically ill spouse—weakens the immune system and makes one more susceptible to becoming physically ill. Physicians and other health professionals are increasingly recognizing the need that couples and families have for assistance in dealing with the psychosocial impact of illness, from infertility and epilepsy to cancer and heart disease. It behooves us in the mental health professions to equip our- selves to deal with these needs. This chapter discusses how illness affects couples, reviews the basics of medical family therapy, and presents a tech- nique for addressing emotional roadblocks in the marital or couple relation- ship that can emerge as couples deal with the particular challenges that illness presents. A REVIEW OF THE LITERATURE ON PSYCHOTHERAPY WITH COUPLES FACING ILLNESS A significant body of research examines the impact of couple relationships on health, and the impact that chronic illness or disability has on the couple (Campbell, 2003; Kiecolt-Glaser & Newton, 2001; Osterman et al. Very few studies, however, focus on couple inter- ventions that might inform psychotherapeutic treatment. We review two cases here and then turn to the clinical literature on couple interventions with medically ill patients that provides guidance for therapists working with this population. Early research focused on couple interventions to improve disease man- agement, medical compliance, quality of life, and mortality for patients with chronic illness. In another controlled study (Taylor, Bandura, Ewart, Miller, & De- Busk, 1985), wives of heart attack patients were asked either to observe their spouse take a treadmill stress test or to take the test with their spouse, three weeks after the heart attack. Wives who walked the treadmill and directly experienced what their husbands were capable of were significantly more confident and less anxious about their husbands’ health and capability than the wives who only observed the test. They were also less overprotective of their husbands, which may relate to the finding that their husbands showed improved cardiac functioning at 11 and 26 weeks after the heart attack. Managing Emotional Reactivity in Couples Facing Illness 255 Although there is a significant body of clinical literature that addresses psychotherapy with families facing illness (see McDaniel, Hepworth, & Doherty, 1992), literature that focuses on helping couples in particular is still relatively scarce—usually found either in textbooks on couples therapy with illness treated as a special issue (e. A wide variety of specific approaches have been offered on the subject of couples and illness, including behavioral (Schmaling & Sher, 2000), existen- tial (Lantz, 1996), and interpersonal (Lyons, Sullivan, Ritvo, & Coyne, 1995). Many of these approaches delineate key issues that couples must con- front when illness strikes and offer strategies, drawn from their particular theoretical framework, to help couples negotiate these issues. Rolland (1994) addresses the impact of illness on intimacy in the couple relationship, focusing in particular on the need for the therapist to assist the couple in addressing the relationship imbalances (skews) that can emerge as a result of illness in one member. Differences in ability that de- rive from the health status of each member of the couple can translate into differences in power and control between them, leading to tension, re- sentment, guilt, distance, and discouragement. Rolland recommends that the couple redefine the illness as "our" problem, rather than "your" or "my" problem, and work as partners to manage the challenges they both face as a result of the illness. Rolland also suggests that therapists as- sist the couple to resist the tendency of illness to dominate the family identity by drawing a boundary around the illness. This can be done by, for example, establishing protected time in which illness talk is off limits as well as by maintaining their pre-illness family and social routines as much as possible. Kowal, Johnson, & Lee (2003) have applied the tenets of Emotionally Focused Therapy (EFT) to working with couples and illness; EFT is an in- tegration of experiential and systemic approaches to therapy that under- stands couple conflict as relating to behaviors and emotions that express underlying attachment needs. They argue that since attachment style has been shown to be related to the onset and exacerbation of chronic illness as well as to a variety of health-related behaviors, then addressing attach- ment needs and the emotions they generate by use of EFT is a promising avenue for assisting couples dealing with chronic illness. They go on to note that "the goals of EFT in working with chronic illness in couples are to normalize and validate each partner’s experience, to help partners process their emotional experiences, to externalize negative interaction 256 SPECIAL ISSUES FACED BY COUPLES cycles, and to help partners seek safety, security, and comfort from each other (i. COUPLES AND ILLNESS—STATEMENT OF THE PROBLEM Factors that influence how illness affects a couple include the nature and severity of the illness; individual variables such as age, gender, ethnicity, general coping style, and previous experience with illness; and relation- ship variables such as degree of conflict, stability, and trust, communica- tion and problem-solving styles, and relationship satisfaction. Issues facing couples dealing with illness include loss—of ability, of a sense of normalcy, of expectations for the future, and possibly loss of life; identity changes precipitated by the presence of the illness; relationship imbalances deriv- ing from the loss of function in the ill spouse; the need to communicate about difficult subjects; establishing the meaning of the illness; the legacy of transgenerational family experiences with illness, vulnerability, and loss; gender issues; caregiver burden and burnout; and the ill spouse’s feel- ings of guilt and uselessness. Literature about helping couples deal with the impact of illness gener- ally addresses the emotional and pragmatic impact of illness on the couple relationship, including loss of function and identity, reassignment of roles, learning to communicate about difficult issues, and so on. What has re- ceived less attention is how to understand and address complicated emo- tional reactions to illness—reactions that seem to go beyond what would be expected, even given the extremely difficult nature of the challenges that illness can present. For some couples, illness presents an opportunity to put things in per- spective, resulting in increased intimacy and relationship satisfaction in the face of challenge. For other couples, the challenge of illness may derail previously adequate coping mechanisms and plunge a formerly stable rela- tionship into a terrifying tailspin. A strain of serious illness can exacerbate prior relationship difficulties and accelerate the deterioration of a couple relationship.

Clinical Grading Scales in Subarachnoid Hemorrhage 165 Metabolic disturbances In comatose patients generic zithromax 100mg with mastercard antibiotic 875, consideration should be given to other conditions causing focal neurological signs order zithromax 500mg on-line 3m antimicrobial gel wrist rest, which often remit when the cause is removed – Metabolic glucose dis- turbances – Renal failure – Severe disturbances of electrolyte balance – Alcohol intoxication – Barbiturate intoxica- tion CT: computed tomography; TIA: transient ischemic attack. Clinical Grading Scales in Subarachnoid Hemorrhage Botterell scale Grade Conscious, with or without signs of bleeding in the subarachnoid space I Drowsy, without significant neurological deficit II Drowsy, with significant neurological deficit III Major neurological deficit, deteriorating, or older with preexisting cerebrovascular disease IV Moribund or near-moribund, failing vital centers, extensor rigidity V Hunt–Hess scale Grade Asymptomatic or mild headache I Moderate to severe headache, nuchal rigidity, may have oculomotor palsy II Confusion, drowsiness, or mild focal signs III Stupor or hemiparesis IV Coma, moribund appearance, and/or extensor posture V Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Syndrome of Inappropriate Secretion 167 Clinical parameter SIADH Cerebral salt-losing syndrome Blood volume Normal or increased Decreased Hematocrit Normal or low Elevated Hydration Well hydrated Dehydrated Body weight Normal or increased Decreased Glomerular filtration rate Increased Decreased Blood urea nitrogen/creatinine Normal or low Normal or high Urine volume Normal or low Normal or low Urine concentration High High Hyponatremia Dilutional (false) True Hypo-osmolality Dilutional (false) True Mean day of appearance 8 (range 3–15) 4–5 (range 2–10) Treatment Fluid restriction Sodium and volume expansion SIADH: syndrome of inappropriate secretion of antidiuretic hormone. Syndrome of Inappropriate Secretion of Antidiuretic Hormone and Diabetes Insipidus The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) involves the release of antidiuretic hormone (ADH) at levels in- appropriate for a low serum osmolality. Due to continued water inges- tion, the elevated ADH results in water retention, hyponatremia, and hypo-osmolality. SIADH results from partial damage to the supraoptic and paraventricular nuclei or neighboring areas, or from production of ADH by tumor or inflammatory tissue outside the hypothalamus. Symptoms of hyponatremia include confusion, muscle weakness, seizures, anorexia, nausea and vomiting, and stupor, when the serum sodium falls below 110mEq/L Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. The clinical symptoms include polyuria (urine output greater than 300mL/h or 500mL/2h), thirst, dehydration, hypovolemia, and polydipsia. Diabetes insipidus results from the de- struction of at least 90% of the large neurons in the supraoptic and para- ventricular nuclei. The lesion often involves the supraoptic and hy- pophysial tract rather than the neuronal bodies themselves. Sodium levels reaching 170mEq/L are accompanied by muscle cramping, tenderness and weakness, fever, anorexia, paranoia, and lethargy Syndromes of Cerebral Ischemia Occluded artery Signs and symptoms Common carotid artery – May be asymptomatic – Ipsilateral blindness Middle cerebral artery – Contralateral hemiplegia (face and arm greater than leg) – Contralateral hemisensory deficit (face and arm greater than leg) – Homonymous hemianopsia – Horizontal gaze palsy – Language and cognitive deficits in the left hemi- sphere: aphasia (motor, sensory, global); apraxia (ideomotor and ideational); Gerstmann syndrome (agraphia, acalculia, left–right confusion, and fin- ger agnosia) – Language and cognitive deficits in the right hemi- sphere: constructional/spatial defects (con- structional apraxia, or apractognosia, dressing apraxia); agnosias (atopognosia, prosopagnosia, anosognosia, asomatognosia); left-sided unilateral neglect; amusia Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Syndromes of Cerebral Ischemia 169 Occluded artery Signs and symptoms Anterior cerebral artery – Contralateral hemiparesis (distal leg more than arm) – Contralateral sensory loss (distal leg more than arm) – Urinary incontinence – Left-sided ideomotor apraxia or tactile anomia – Severe behavior disturbance (apathy or "abulia," motor inertia, akinetic mutism, suck and grasp re- flexes, and diffuse rigidity—"gegenhalten") – Eye deviation toward side of infarction – Reduction in spontaneous speech, perseveration Posterior cerebral – Contralateral homonymous hemianopia or quad- artery rantanopia – Memory disturbance with bilateral inferior tem- poral lobe involvement – Optokinetic nystagmus, visual perseveration (palinopsia), hallucinations in the blind field – There may be alexia (without aphasia or agraphia), and anomia for colors, in dominant hemisphere in- volvement – Cortical blindness, with patient not recognizing or admitting the loss of vision (Anton’s syndrome), with or without macular sparing, poor eye–hand coordination, metamorphopsia, and visual agnosia when cortical infarction is bilateral – Pure sensory stroke: may leave anesthesia dolorosa with "spontaneous pain," in cortical and thalamic ischemia – Contralateral hemiballism and choreoathetosis in subthalamic nucleus involvement – Oculomotor palsy, internuclear ophthalmoplegia, loss of vertical gaze, convergence spasm, lid retrac- tion (Collier’s sign), corectopia (eccentrically posi- tioned pupils), and some times lethargy and coma with midbrain involvement Anterior choroidal May cause varying combinations of: artery – Contralateral hemiplegia – Sensory loss – Homonymous hemianopia (sometimes with a strik- ing sparing of a beak-like zone horizontally) Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. CN III brachium con- movements (intention tremor, junctivum hemichorea, or hemiathetosis) Claude’s! Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. CN V superior colliculus MLF medial geniculate ventral + lateral body spinothalamic tracts Substantia nigra medial lemniscus cortico- mesencephalic pontine reticular tracts formation pyramidal tract red nucleus (corticospinal) CN III Parinaud syndrome Claude syndrome Benedict syndrome Weber syndrome a Fig. Benedict syndrome: a) red nucleus (contralateral involuntary movements, including intention tremor, hemichorea, and hemiathetosis; b) brachium conjuctivum (ipsilateral ataxia); c) parasympathetic root fibres of CN III (ipsilateral oculomotor paresis with fixed and dilated pupil). Claude syndrome: a) dorsal red nucleus (contralateral involuntary movements, including intention tremor, hemichorea, and hemiathetosis; b) Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Parinaud sydrome: a) superior colliculi (conjugated gaze paralysis upward); b) medial longitudinal fasciculus (nystagmus and internal ophthalmoplegia); c) eventual paresis of the CNs III and IV; d) cerebral aqueduct stenosis/obstruction (hydrocephalus). Brain Stem Vascular Syndromes 173 c inferior cerebellar penduncle MLF CN V nucleus and tract pontine reticular formation medial lemniscus CN VIII CN VII ventral and lateral spinothalamic tracts pyramidal tract pontine tracts CN VI locked-in syndrome dorsal pontine (Foville) syndrome ventral pontine (Millard-Gubler) syndrome c Fig. Ventral extension of the lesion involves additionally; c) cor- ticospinal tract (contralateral hemiparesis), d) paramedian pontine reticular for- mation (paralysis of the conjugate gaze towards the side of the lesion). Marie– Foix syndrome: a) superior and middle cerebellar peduncles (ispilateral cerebel- lar ataxia); b) corticospinal tract (contralateral hemiparesis); c) spinothalamic tract (variable contralateral hemihypesthesia for pain and temperature). Midpon- Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Millard–Gubler syndrome: a) pyramidal tract (contralateral hemiplegia sparing the face); b) CN VI (diplopia accentuated when thepatient"lookstowards"thelesion);c)CNVII(ipsilateralperipheralfacialnerve paresis). Locked-in syndrome: a) bilateral corticospinal tracts in the basis pontis (tetraplegia); b) corticobulbar fibres of the lower CNs (aphonia); c) occasionally bilateral fascicles of the CN VI (impairment of horizontal eye movements). Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Tsementzis, Differential Diagnosis in Neurology and Neurosurgery © 2000 Thieme All rights reserved. Clumsiness and paresis of the hand syndrome infarction) at junc- hand, ipsilateral hyperreflexia, tion of upper one- and Babinski sign third and lower two-! CN VII dysphagia Differential diagnosis: this syndrome has also been described with lesions in a) the genu of the internal capsule or b) with small deep cerebellar hemorrhages. With or without facial involve- spinaltractsinthe ment basispontis Ataxic hemiparesis! Hemiparesis more severe in the volving the basis lower extremity pontis at the junc-! Occasional dysarthria, nystag- third and lower two- mus, and paresthesias thirds of the pons Differential diagnosis: this syndrome has also been described with lesions in a) the contralateral thalamocapsular area, b) the contralateral posterior limb of the internal capsule, and c) the contralateral red nucleus Locked-in syn-!

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With most contemporary health insurance arrangements order 250mg zithromax with mastercard antibiotic quinine, a referral from a primary care physician to a specialist may be required before the insurer will cover the treatment episode safe zithromax 500mg antibiotic probiotic. Depending on their specialty, physi- cians may also depend on referrals from nonphysician providers. Providers such as psy- chologists, optometrists, and chiropractors may make referrals to psychiatrists, ophthalmologists, and neurosurgeons, respectively, if the treatment requirements exceed their capabilities. Mental health centers and social service agencies may be major sources of patients for some specialists, as these agencies represent the front line of contact with many potential patients. Prescription drugs are becoming an increasingly important aspect of patient care, and this area also involves indirect access to the end user. Except in the case of over-the-counter drugs, pharmaceutical companies cannot deal directly with patients. The patient must have a prescription written by a physician to obtain the drug from a pharmacist, and numerous safeguards prevent unauthorized access to prescription drugs. The pharmaceutical company relies on the physician to recommend its brand of drug, and, understandably, the main thrust of pharmaceutical marketing is toward physicians. A final example of the referral process involves the steering of patients on the part of health insurance plans. Whether a plan is offered by a traditional indemnity insurer, health maintenance organization, preferred provider organization, or employer with a self-insured plan, there will virtually always be restrictions placed on providers that can be used. Typically, a health plan will have an arrangement with a network of providers, and the plan enrollee will be channeled to one of these providers rather than an out-of- network provider. Thus, the choice of physician, hospital, home health agency, and other providers is likely to be essentially outside the control of the end user. In these cases it is more important for the provider to develop relationships with the various health plans than to market directly to patients. Services come in bundles—the group of services that surrounds a particular surgical procedure, for example. While clinicians (and their billing clerks) may see them as discrete services, the patient perceives them as a complex mix of services related to heart care, diabetes management, or cancer treatment. As will be seen in the discussion of healthcare products in Chapter 8, the "products" generated by a healthcare organization are difficult to conceptualize. The difficulty in specifying the services provided becomes obvious to the marketer who asks a hospital department head what services the department provides. A substitute is a good or service that can be used in place of another good or service. While one form of transportation may be substituted for another, for example, the opportunity to substitute one surgical procedure for another seldom exists. Unlike other industries, healthcare often provides only one solution for a particular need. Health Professionals The healthcare industry has been historically dominated by professionals rather than administrators. Clinical personnel (usually physicians, but other clinicians as well) define much of the demand for health services and are responsible directly or indirectly for the majority of healthcare expendi- tures. This is comparable to a situation in other industries in which tech- nicians rather than administrators run the industry. However, this situation in healthcare is more significant in that the clinicians may not have the same goals and objectives as the administrators. The medical ethics that drive the behavior of health professionals exist independent of the operation of the system. Clinicians are bound by oath to do what is medically appropriate, whether or not it is cost effec- tive or contributes to the efficiency of the organization. Decisions made in the best interests of the patient may not reflect the best interests of the organization. Although health professionals have had to become somewhat more realistic with regard to indiscriminate use of resources, clinical inter- ests continue to outweigh financial considerations in most cases. Conflict between the respective goals of clinicians and administrators is an inherent feature of the healthcare organization, and no comparable situation can be found in any other industry. The Challenge of Healthcare M arketing 31 The conflict between the clinical and business sides of the health- care operation is augmented by an antibusiness orientation that character- izes many health professionals. Most health workers entered the field because they wanted to be in a profession, not a business, and many physicians and other clinicians hold a distorted perception of the business world.

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Syncope in the atenolol in patients with unexplained syncope and positive elderly purchase 500mg zithromax treatment for dogs collapsing trachea. Di Girolamo E order 100 mg zithromax visa antibiotic resistance assay, Di Iorio C, Sabatini P, Leonzio L, Barbone examination, and electrocardiography. Effects of paroxetine hydrochloride, a selec- assessment project of the American College of Physicians. The North clinical efficacy assessment project of the American College American Vasovagal Pacemaker Study (VPS). Pacemaker versus no therapy: a mul- monitoring in patients with syncope: is 24 hours enough? Use of extended monitoring patients with lethal ventricular arrhythmia resume driving? Surgical treatment of neuropathic and effect of topically applied recombinant basic fibro- ulcerations under the first metatarsal head. Peripheral neuropathy and the diabetic chronic diabetic neuropathic ulcer of the foot. Surgical correc- silver sulfadiazine, povidone-iodine and physiologic saline tion of pressure ulcers in an urban center: is it efficacious? Management of stage III nidazole therapy for anaerobically infected pressure sores. Foot-ulcer prevention in the the microbial flora of healing and non-healing decubitus elderly diabetic patient. Treatment of leg ulcers with split management of uncomplicated lower-extremity infections skin grafts: early and late results. Air-fluidized beds or conventional therapy for pressure sores: a randomized AHCPR Pub 95-0652. Finally, patterns on floors or walls, changes in dose and the total number of medications depending on their quality, may either distort or improve have been associated with an increased risk of falling. Drop attacks may occur while walking, while have attempted to identify the "most likely cause of indi- turning the neck, while looking up, or without an obvious vidual falls," falling among nursing home residents, as precipitating movement. Some individuals note that their among community-living residents, most often results knees buckled or "just gave out. The prevalence of the impairments is higher etiology and frequency of drop attacks are unknown. Similar to community studies, studies of nursing obvious intrinsic or environmental cause is reported in home residents have identified an increased risk of falling less than 5% of falls. Only a small percentage of falls occur during clearly hazardous activ- Host factors such as acute illness, postural hypotension, ities such as climbing on chairs or ladders or participat- dizziness, or medications have been described. Also, by ascertain because studies lack control data on nonfallers and large, institutions are safer environments than the or fallers at times other than their fall. Nutrition 1011 be life threatening, warrant hospitalization, and necessi- uration, is frequently misdiagnosed as iron-deficiency tate a prolonged period of recuperation. This error results in the inappro- For these, aggressive attempts at assuring adequate priate administration of oral iron therapy and unneces- hydration are essential in the elderly. Furthermore, this sary invasive investigative procedures to identify the must commence soon after the development of a minor source of iron loss. Patients and their families ciated with an impaired ability of the reticuloendothelial must be educated to emphasize the importance of main- system to recirculate iron obtained from the breakdown taining adequate fluid intake at all times and to carefully of phagocytosed senescent red cells. Thus, in the anemia monitor intake if a minor illness develops or if fluid of chronic disease, iron stores are normal or increased, requirements are increased, as occurs during heat waves. In the hospitalized older patient, the possibility that con- Recent studies indicate a correlation between in- fusion or delirium is caused by dehydration should be creased iron stores and risks of neoplasia and coronary high on the differential diagnosis list. Because aging is associated with increas- assure that their patients have adequate access to water. Consuming a multivitamin monitored by frequent weight and intake and output with minerals containing the RDA for iron, combined measurements. If current evidence confirms adverse effects of iron stores, the use of iron-containing supplements in the elderly may well be unwise. Numerous studies indicate that, for a wide variety of min- erals and vitamins, intake is significantly lower than the RDA for a large proportion of ambulatory elderly.

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